Appendix 1 PAEDIATRIC Point Prevalence Survey Ward Form Please fill in one form for each ward included in PPS Date of survey Person completing form (Auditor code) Hospital Name Department/Ward Paediatric departments GPMW (General Paediatric Medical Ward) Department/Type: Place a tick against the type of department HO-SPMW (Haematology-Oncology Special PMW) C-SPMW (Cardiology Special PMW) T-SPMW (Transplant (BMT/Solid) Special PMW) Other-SPMW (All other Special PMWs) PSW (Paediatric Surgical Ward) PICU (Paediatric Intensive Care Unit) Mixed Department Yes No Activity: Please tick as appropriate. In case of mixed departments, tick all the encountered specialities Medicine Surgery Intensive Care Total number of patients on the ward present at 8.00 am day of PPS by specialty. In case of mixed department, fill the total number of patients corresponding to each of the encountered specialities. Total number of beds on the ward at 8:00 am day of PPS by speciality For mixed departments fill in the total number of beds corresponding to each of the encountered specialities. Include only patients admitted before 0:00 hours the day of the PPS. Do not include patients admitted after 8am on the day of the PPS.
ANNEX 1 UNDERLYING DIAGNOSES GROUPS: PAEDIATRIC PATIENTS (Select a maximum of 3 diagnoses out of the 14 categories below). 1. Surgical disease/malformations including all problems requiring surgical intervention/ follow up, e.g. gut malformations/atresia, Urinary malformations, Sacral agenesis, Central Nervous System malformations, skin anomalies treated surgically including abscesses, any device insertion including gastrostomies, urinary catheter or Ventricular-peritoneal shunt, etc. 2. Chronic Neurological and Psychiatric disorders including Cerebral Palsy, Global Developmental Delay (GDD), all seizure disorders (epilepsy, West syndrome, etc.), progressive neurological and neuromuscular syndromes. 3. Gastroenterological disease including inflammatory bowel disorders, Gastrooesophageal reflux requiring treatment, Celiac disease, chronic non-infectious liver diseases, etc. 4. Congenital Heart Disease (CHD) including all the cardiac malformations and acquired cardiac disease e.g. Kawasaki, and cardiac surgery 5. Oncologic/Hematologic diseases and Bone Marrow Transplantation except immune deficiencies unless after bone marrow transplantation and all Solid Organ Transplantation. 6. Chronic Endocrinological Diseases including Cushing syndrome, thyroid disorders, pituitary gland disorders, etc. 7. Chronic Renal Disease, including Vesico-ureteric reflux. 8. Chromosomal/Single gene/metabolic disorders (diabetes). 9. Rheumatological, autoimmune and chronic inflammatory diseases such as LED, sarcoidosis etc. 10. Chronic lung diseases including cystic fibrosis and chronic lung disease in ex preterm patients. 11. Chronic infectious diseases such as HIV, tuberculosis with ongoing treatment and chronic hepatitis B or C infection or primary immunodeficiencies. 12. Allergies (only drug allergies and no other allergies). 13. Other/Unknown 14. No underlying disease
ANNEX 2 LIST OF REASONS FOR TREATMENT, PAEDIATRIC PATIENTS (For each antimicrobial select only 1 out of the 21 categories below. If more categories are possible, write the one most applicable.) 1. Treatment for Surgical disease: PROVEN OR SUSPECTED INFECTION e.g. peritonitis, appendicitis, abscess, epdidymitis, ANY case of acute abdominal problem admitted under the surgical team, mediastinitis, etc. 2. Prophylaxis for Surgical disease: PREVENTION OF AN INFECTION e.g. prophylaxis for any surgery and ANY case in which antibiotics are used for prophylaxis and not to treat a suspect infection for a surgical condition, etc. 3. Prophylaxis for Medical problems e.g. prophylaxis in people with sickle cell disease, urinary tract infection, immunosuppression, nephritic/nephrotic syndrome, chronic lung disease, chronic rheumatological diseases, rheumatic fever, etc. 4. Sepsis (includes cases of suspected Sepsis syndrome or presumed bacteremia/septicaemia). 5. Central Nervous System (CNS) infections (includes possible, probable and definitive meningitis, encephalitis, meningo-encephalitis, myelitis, etc.). 6. Cardiac Infections including endocarditis, pericarditis, myocarditis, etc., but not endocarditis prophylaxis during surgical procedures. 7. Upper Respiratory Tract Infections (URTI) including rhinitis, sinusitis, pharyngitis, tonsillitis, adenoitidis, laryngitis, laryngo-tracheitis, epiglottitis, etc., but not acute otitis media (see below). 8. Acute Otitis Media (AOM) 9. Proven or probable Viral Lower Respiratory Tract Infections (LRTI) including bronchitis, bronchiolitis, etc. 10. Proven or probable Bacterial LRTI including pneumonia/empyema 11. Tuberculosis (TB). 12. Lymphadenitis unless requiring surgical intervention. 13. Urinary Tract Infections (UTI): Cystitis and pyelonephritic including urinary catheter-related UTI. 14. Skin/Soft Tissue Infections including Staphylococcal Scalded Skin Syndrome, cellulitis, folliculitis, etc. 15. Joint/Bone Infections including septic arthritis, osteomyelitis, etc. 16. Pyrexia of Unknown Origin (PUO) with exception of fever in oncologic patients and febrile neutropenia. 17. Febrile neutropenia/fever in oncologic patients. 18. GI tract infections including shigellosis, salmonellosis, giardiasis etc. 19. Probable or proven Catheter Related Blood Stream Infection (CRBSI). 20. Malaria 21. Other/Unknown.
ANNEX 3 INDICATION CODES FOR PAEDIATRIC PPS A Community acquired infection Symptoms or antibiotics start <48h after admission to hospital B Hospital acquired infection Symptoms or antibiotics start 48h after admission to hospital B1 Post-operative infection (within 30 days after surgery or 1 year after implant surgery) B2 IV catheter intervention related infections B3= not existing B4 Other hospital acquired infection including VAP and CAPD* B5 Infection present on admission from another hospital C Surgical prophylaxis** C1 Single dose C2 multiple doses within one day C3 >1 day D Medical prophylaxis All medical prophylaxis * VAP= ventilator Associated Pneumonia; CAPD= Continuous Ambulatory peritoneal dialysis ** For surgical patients, administration of prophylactic antimicrobials should be checked in the previous 24 hours in order to encode the duration of prophylaxis as either one dose, multiple doses given on one day or >1 day. Type of treatment E versus T Empirical treatment (E) = empiric when the antibiotic is being used as per a local guideline as a best guess - treatment by means which experience has proved to be beneficial. Targeted treatment (T) = based upon microbiological culture and/or sensitivity testing, the action of the remedies given are directed against the cause of the disease (e.g. positive blood or sputum culture). Note down the information which is available at the time of survey (e.g. empirical even when confirmation positive blood culture day after survey) Ventilated Note down the status at 8am on the day of the survey. Inv.V = yes, invasive ventilation NonInv.V = yes, non-invasive ventilation. These include continuous positive airway pressure (CPAP), nasal continuous positive airflow pressure (ncpap) and Bi-Level Positive Airway Pressure (BiPAP ) No vent. = no ventilation
Ward Name/code Activity 1 (M, S or IC) PATIENT Form (Please fill in one form per patient on antimicrobial treatment) Patient Identifier 2 Survey Patient Age Gender Number 3 Years Months Days M or F Weight (in kg, 2 decimals) Ventilated Inv.V / Non-Inv.V / No Vent. UNDERLYING DIAGNOSES Enter category numbers 1 to 14 MAXIMUM of three categories can be entered. (See Annex 1 for categories numbers) Drug (Antimicrobial name, generic or branded) 1 Single Dose 4 Numeric Unit mg or IU Doses per day 5 Route6 P, O, R, I Reason for Treatment See Annex 2 Enter category 1-21 Indication 7 A, B1-B5, C1- C3 or D Treatment E=Empirical T = Targeted See Annex 3 Reason in notes Co-amoxiclav 125 mg 3 O 10 A E Yes (Yes/No) 2 3 4 5 1 Activity: specify only when the department is a mixed department (M: Medicine, S; Surgery, IC: Intensive care) 2 Enter the patient s unique hospital number to allow local linkage to patient records for more detailed audit if required. This identifier will not be entered onto the electronic database and is for internal use only. 3 Survey Number: a unique but non-identifiable number given for each patient by the ARPEC WebPPS - please leave blank. But, note down this number after patient has been recorded in the ARPEC online database! 4 Single dose per administration in mg or IU. For combination products, e.g. co-amoxiclav 125/31 mg (amoxicillin 125 mg + clavulanic acid 31 mg as potassium salt) should be entered as 125 mg (see protocol). 5 Provide fractions of doses if necessary, e.g. every 16h = 1.5 doses per day, every 36h = 0.67 doses per day, every 48h = 0.5 doses per day 6 Route of administration: P: Parenteral, O: Oral, R: Rectal, I: Inhalation; exclude topical use applied on skin. 7 A = community acquired; B1 = hosp. acquired, post-operative infection; B2 = hosp. acquired, IV catheter related infection; B4 = other hospital acquired infection including VAP & CAPD; B5 = infection present on admission from another hospital; C1 = surgical prophylaxis single dose; C2 = surgical prophylaxis multiple doses given in one day; C3 = surgical prophylaxis >1 day; D = medical prophylaxis: See Annex 3.